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Abstract

Electronic textbooks have become available in recent decades as replacements or alternatives for print versions. The aim of this descriptive cross-sectional study was to evaluate the use of electronic versus print textbooks by Chilean dental students. The target population was students from 14 Chilean dental schools. The questionnaire was adapted and translated to Spanish from a previous survey used in a similar study. It consisted of the following variables: preferred type, type used, frequency of use, source, electronic devices used to read, and disposal after use. The use of textbooks was analyzed and compared by gender and course (p≤0.05). The final sample consisted of 3,256 students (21.38±2.5 years of age, 50.8% women). Most of the participants reported using both types of texts, with most (63.9%) preferring print over electronic texts, including significantly more women (p<0.001) and first-year students (p<0.001). Most of the participants (82.8%), more women (p<0.001), and with variations over years of study (p<0.001) reported that they printed out their electronic texts, and 91.8% kept their printed material. Most of the students used electronic books on a daily basis (47.3%) or at least twice a week (30.7%). The main source of electronic textbooks was the Internet (43.8%). A personal computer was the most widely used device for reading electronic texts (95.0%), followed by a cell phone (46.4%) and a tablet (24.5%). Overall, these Chilean dental students preferred print over electronic textbooks, despite having available electronic devices.

Electronic books have been around since the 1970s; however, their use began to increase with the mass appearance of electronic devices such as computers, cell phones, and tablets. This situation has significantly changed the publishing industry. The current generation of university students has grown up with electronic devices, a remarkable difference from previous generations.1 While some have claimed that students’ familiarity with technology surpasses the computer capabilities of their teachers,2 it is increasingly common that teachers have knowledge and computer skills similar to their students.

Studies in health professions education have had mixed results. In medical education, two studies found students preferred to learn from digital versions of textbooks, but there were no significant differences between the test scores of those who used print versus electronic texts.3,4 While Christianson and Auicon found a greater preference for electronic texts in the scientific area,5 Phua and Lim reported that medical interns and residents preferred print books,6 and Ditmyer et al. concluded that dental students in the U.S., Puerto Rico, and Canada in their study had no specific preference.1 Despite the advantages of mobility and visualization offered by e-books, these are not considered sufficient reason to replace print texts. Moreover, there are disadvantages such as increased time consumption, difficulty of use, and the presence of distracting elements for reading.7–9

Given the variety of choices between electronic and print textbooks, it is important to explore dental students’ preference for one format or the other to guide the future development of libraries and curricula in dentistry. The aim of this study was to evaluate the use of electronic versus print textbooks by Chilean dental students.

Methodology

This study was approved by the Ethics Committee of the Faculty of Medicine of the Universidad Austral de Chile. The target population for this descriptive, cross-sectional study was students from 14 Chilean dental schools. Inclusion criteria were students from first to fifth years at universities that permitted the questionnaire to be distributed between May and June 2014 and students who agreed to participate in the study. Final-year students were excluded because they are in residencies in public hospitals and thus not available at the time of the survey. The sample size was estimated considering the following parameters: a total of 12,478 dental students in Chile,10 an a priori preference of 50% for electronic textbooks, a confidence level of 95%, a power of 80%, and an estimated error of 2%. The sample size was estimated at a minimum of 2,114 students.

Questionnaire: Translation and Adaptation

We used a modified version of the questionnaire developed by Ditmyer et al. for use in a descriptive study assessing dental students’ attitudes about computer use related to study habits and e-textbooks conducted in dental schools in North America.1 Their instrument consisted of a combination of selected-response questions and closed-ended questions about students’ computer use, study habits, use of e-textbooks versus print textbooks, and demographic information.

Two of the investigators translated the Ditmyer et al. questionnaire into Spanish and adapted it for use in Chile. A pilot application was administered to ten faculty members and 25 students from the School of Dentistry at the Universidad Austral de Chile to evaluate the instrument’s face validity. Considering the feedback on this initial application, two researchers made modifications and linguistic adaptations to the original scale. In a second pilot to analyze the test-retest reliability, 32 fourth-year dental students completed the questionnaire on two occasions with a one-week interval. The Kappa coefficient was 0.82. The final version of the instrument had 15 questions in four domains: general information, use of electronic textbooks, use of print textbooks, and demographic information.

Data Collection and Analysis

Deans and directors of all 14 Chilean schools of dentistry were invited by email to have their schools participate in the study. After agreeing to participate, they were contacted via telephone to coordinate distribution of the questionnaire to students at their schools. Two of the investigators conducted the surveys in person using paper instruments. Students attending any class during the time and day of the appointment were invited to participate. The survey was conducted at the beginning or end of the class. On site, the two researchers gave an oral presentation of the study aim and answered questions, avoiding any bias in the students’ responses. Completion of the surveys was anonymous and on a volunteer basis. Students had ten minutes to complete the questionnaire.

Electronic textbooks were considered those in the following formats: doc, docx, PDF, DjVU, ePub, HTML, lit, mobi, OEB, oPF, prc, RTF, aeh, azw, BBeB, CBR/CBZ, CHM, DTB, FB2, Irf, pdb, pml, rb, TCR, TR2, TR3, WOLF. Scanned documents were also considered electronic study texts. All electronic texts had to be visible on a device screen (computer, cell phone, tablet, or e-reader). Devices were considered any electronic machine or gadget designed to control and exploit electrical signals, disseminating dynamic information to meet information and training needs. Print textbooks were considered those available on paper. Sources were considered any origin of the electronic or print texts.

All collected questionnaires were tabulated and stored in a Google Drive database (Google Inc., Menlo Park, CA, USA). The use of textbooks was analyzed and compared by gender and course using a chi-square test with significance set at p≤0.05. All analyses were done with STATA 10.0 (STATA Corp., College Station, TX, USA).

Results

The total participants were 3,256 students from 14 dental schools. The selection process is shown in Figure 1. Of the participants, 1,955 were women (60%), and the average age was 21.38±2.52 years. The distribution by gender and year of study is shown in Table 1. Most participating students (92.3%) used both types of formats, followed by exclusively print (5%) and exclusively electronic (2.7%). There were no statistically significant differences between men and women (p=0.262), but there were between years of study (p=0.006).

Type of textbooks used in participating dental schools by gender and year of study

Women participants preferred the print books more than did the men participants (p<0.001), but the preference of use and actual use had different patterns. In particular, there was a drop in the preference for print books and an increase in electronic ones from early to later in the program (p<0.001) (Figure 2).

Type of texts preferred by students, by gender and year of study (n=3,256)

Most of the participating students (84.6%) printed out their electronic books, a finding significantly higher for women than men (p<0.001). There was also a statistically significant difference between the years of study in printing out e-books (p<0.001), but without a clear pattern across years (Figure 3). Most of these students printed out the books on their own (82.8%) or at the university (12.7%) or got them from classmates (2.8%). There were statistically significant differences in how students printed out their e-books by gender (p=0.01) and by course (p<0.001), but with no clear pattern. Most students kept their printed material (91.8%), while small numbers disposed of it (4.2%) or recycled it (3.0%).

Students who reported printing out electronic books (Yes), by gender and year of study (n=3,256)

The most frequently used way that these students reported obtaining e-books was the Internet (43.8%), followed by professors (33.2%), classmates (22.6%), and stores (0.4%). There were significant differences in methods of obtaining e-books by year of study (p<0.001), but no significant difference by gender (p=0.16) and with no clear pattern. Most participants used electronic books on a daily basis (47.3%) or at least twice a week (30.7%). There were differences in frequency of use by year of study (p<0.001) but not between men and women (p=0.084). The PC was the most frequently used device to read e-books (95.0%), followed by cellphones (46.4%) and tablets (24.5%) (Figure 4).

Device students used to read electronic books, by gender and year of study (n=3,256)

Discussion

The dental students who participated in this study used both electronic and print textbooks. However, four out of five printed out their electronic texts, mainly women and students in the first and second years. E-learning has allowed dental students to have greater access to information through the use of electronic texts that include search and interactivity tools.11–13 Many sources for such documents are available, including universities, external platforms, and websites offering original documents scanned without formal authorization from the authors or publishers.11

Despite the wide access to and use of print and electronic documents,1,5 most of the students in our study preferred print ones, which is similar to previous reports.6,9,12,14 Furthermore, students in our study mainly preferred to print out electronic texts, and only 2.7% used e-books exclusively. This preference is similar to that found among students in the U.S., where 59.8% preferred print texts in general and 37.2% said they preferred print texts instead of reading on the computer.9 The investigators in that study noted that the students’ choice was related to key elements in the learning method, such as the possibility of handwritten notes or transporting the document without the need of an electronic device. In addition, electronic texts have some disadvantages, including distraction, lack of deep reading, wasting time on non-academic sites,15 disorientation,16 and eye strain.12 A preference for print over electronic texts is not simply impulse: it is easier to write on print texts, which facilitates both sensory-motor representations17 and symbolic understanding.18

Among the participants in our study, the choice of print over electronic texts varied significantly across year of study: in the junior year, students had greater preference for print texts, but that preference decreased in the senior year. This finding differed from what was reported by Ditmyer et al., who found students’ age and year of study had no effect on text preference.1 This difference may be due to the minimal use of e-learning in Chilean secondary schools, so that students enter post-secondary education accustomed only to print-based learning.

Despite the increasing supply of electronic books in the last two decades led by global online stores like Amazon and Apple Ebook Store,12 in our study fewer than 1% of the participants reported having paid for e-books from online stores, well below the 26.2% reported by students in the U.S.1 Our finding suggests that some e-texts being used may not be the publishers’ versions, but copies created by students with text and/or scanned images from original sources. Such a practice implies that unreliable documents may be circulating and/or piracy is taking place,13,14 practices found in another study to occur with three out of five students.19 This situation is a call to university authorities to monitor the sources and documents used by their students. Our results can help guide future research to evaluate the type of information contained in both formats (original articles, scanned books, notes, lectures, etc.), which would make it possible to assess the level of scientific evidence used by students across years of study and disciplines. It is also important to determine whether the texts used by students comply with copyright restrictions.

One-third of the students in our study reported getting digital documents from their teachers or the university library. This finding is important to analyze because instructors have been found to prefer to use print texts and may be reluctant to use electronic texts.20,21 Our study did not assess the kind of electronic texts distributed in class, but it would not be surprising if these were ready-to-print with no interactive capabilities. On the students’ side, access did not seem to be the problem, but rather the motivation to explore innovative ways of learning, such as e-learning. Uribe and Mariño, studying a group of Chilean dental students, found that one out of five used the Internet to search for medical-academic information.22 A similar situation was reported in Jordan, where 74% of students had access to computers at home but said they were most frequently used for personal rather than academic purposes.23

The study had some limitations that should be considered. The student sample was obtained by convenience, so it may not be truly representative of national preferences for print over electronic texts. The questionnaire consisted of closed questions only, which restricted the respondents in expressing their opinions, and it assessed only certain aspects of the use of texts. Despite these limitations, this study is the first report available regarding the use of study texts by dental students in Chile or any other Latin American country. Future research should explore further the use and impact of other information and communications technologies (ICTs)22 on dental education, such as podcasts,24 online video lectures,25 and online tutorials.26,27

Conclusion

The Chilean dental students in this study preferred print over electronic textbooks, despite having access to electronic devices to read them. Further research should focus on technology patterns of use, the evidence level of electronic study texts, and the impact of ICTs on Chilean dental education.